William Grieve

Dear Miss Serrano

Regulation 28 Report – Prevent Future Deaths – William Anthony Grieve

During the course of the inquest for William Anthony Grieve which concluded on 17th March 2025, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows:

(1) Evidence emerged during the inquest that Mr Grieve was under the care of Stoke Talking Therapies, and had also presented at the Stoke Crisis Resolution Evolution Team. Both had conducted suicide risk assessments of Mr Grieve. (2) Both assessments, were incorrect, and took account of incorrect information because neither team had access to the others computer system. Stoke Talking Therapies used IAPTUS and Crisis resolution used Lorenzo. There was no way for either team to see the others electronic notes. (3) It was said in evidence, that a member of staff had not carried out a risk assessment properly whoever, nothing had been done to address this and there were no plans to address this. The concern being that staff training needs are not being addressed.

Trust responses to Matters of Concern Above (see appendix 1 for Action Plan)

(1) We agree with this statement. A patient at any given time can have touch points/points of entry with different mental health services dependent upon their clinical need at that time. Each clinical team will undertake a clinical assessment in that moment including risk assessment in order to formulate how best to support those needs. More than one risk assessment could be open at any given time when patients are accessing different services.

Chief Medical Officer Trust Headquarters Lawton House Bellringer Road Trentham ST4 8HH

Chair:

Chief Executive:

It is important that services are accessible and responsive to changeable and different needs at any time, it is quite often the case that people can be open to several services at the same time.

(2) Nationally IAPTUS are not set up to share their electronic patient records as the provider of this system has outlined below the reasons for this: Secondary care providers do not have access to the IAPTUS system. There are important, considered, reasons for this.
i. Talking Therapies in Staffordshire and Stoke on Trent treat a large number of NHS staff for therapy. They have been consented that their notes will remain confidential from other NHS services unless there are issues of risk or safeguarding, to assure them that their colleagues will not be able to view those psychological therapy notes. To open this access to IAPTUS and other NHS Staff poses a risks of breaches of confidentiality and a risk that staff will no longer come forward to access the service.

ii. All patients have been consented on the basis that only their direct care team will have access to their notes. As around 30,000- 40,000 patient records are created annually on the system, it would be impossible to re-consent those people historically if access to the system was to change.

iii. Staff supervision notes, which are notes which document oversight and input from a supervisor and any guidance provided to ensure the quality of the service provided and to ensure that staff receive the necessary support and feedback to perform their roles effectively, are held on IAPTUS. They are held separately to patient records. There is no way of restricting access to these notes to other users.

iv. If access were to be widened (which due to points 1,2 and 3 above is currently not something we are considering) additional user accounts would need to be created.

v. If access were given to NSCHT staff, equivalent access would need to be offered to all partners organisations on the contract making the system unwieldy. Very complex Data Protection Impact Assessments would be required regarding information sharing due to the complexities of the number of partner organisations working on the contract and the information all of them would be able to view.

vi. Nationally, it is not usual practice that secondary care staff have access to the Talking Therapies record system for the clinical and cost reasons outlined above. If urgent or serious risk presents in Talking Therapies services, it is standard and expected practice that these risks should be escalated to secondary care within the system immediately as per Talking Therapies national guidance, due to there being no medical staff in the team to advise on this.

Chair:

Chief Executive:

vii. There is no block within the IAPTUS system to enable users to access only parts of the notes – if access is grated the entire record, plus supervision notes, will be viewable.

An Integrated Care Record (ICR) – already exists and NSCHT, MPFT, UHNM and GP services each extracts an agreed dataset of information to this ICR system and NSCHT aim to take forward discussions with MPFT to do the same from IAPTUS electronic patient record to mitigate some of the system issues raised.

(3) This evidence was in relation to a member of staff within the Crisis Resolution Home Treatment Team (CRHTT), not Talking Therapies. Upon further review, risk assessments were completed for Mr Grieve. Early organisational learning has led to a review of the standard operational procedure for service users who do not attend appointments the principles of this being adopted immediately whilst awaiting Trust governance approval processes. Please see attached action plan below. Do not hesitate to contact me should you need any further information.

Dear Ma’am, Regulation 28 Report into the death of Mr William Anthony Grieve Midlands Partnership NHS Foundation Trust (“MPFT”) acknowledges receipt of the Regulation 28 Report to Prevent Future Deaths following the inquest into the tragic death of Mr Grieve. On behalf of MPFT I would first like to offer my sincere condolences to Mr Grieve’s friends and family for their tragic loss. MPFT provides the following response to the Regulation 28 Report. It is important to note at the outset that MPFT were not notified of Coroner’s investigation had no input into the inquest process, and, were not present at the final court hearing, as such, were not privy to any of the evidence which led to your concerns. This response is provided in absence of any knowledge of the evidence. Further, this response will only refer to matters which are directly under MPFT’s knowledge and control. MPFT take a collaborative approach with other colleagues and have met with representatives at North Staffordshire Combined Healthcare Trust (“NSCHT”) in relation to your concerns raised in your Regulation 28 report. MPFT are committed to continuing this collaborative approach and always take any concerns and issues with care seriously and are dedicated to continually improving patient safety and learning. Talking Therapies- MPFT MPFT holds the contract for Talking Therapies in Staffordshire and Stoke on Trent, and sub- contracts to other partners. There are 7 different organisations who sub-contract from MPFT, NSCHT are one such provider. NSCHT provide the Talking Therapies services in Stoke, who I understand provided treatment to Mr Grieve. NSCHT are responsible for the provision and performance of this service and are responsible for oversight of mandatory training of all staff working in the Stoke locality team. However, if MPFT

LEGAL\118240\00072\74212422.v1-6/6/25 make a change to the whole contract in terms of the expectations regarding staff training MPFT would take responsibility for delivering that training. MPFT oversee the provision of the service by monthly national reporting, which is collated by the MPFT Business Intelligence Team and by quarterly reporting by partner organizations into the NHS Talking Therapies Governance Board, chaired by the MPFT Director of Operations and attended by commissioners/the ICB. MPFT would expect any concerns held by any of the sub-contractors to be raised in line with the contract. Where concerns are with MPFT Clinical Director and Deputy Clinical Director would work closely with managers in the Stoke locality to assist them in rectify any issues. Electronic Record Keeping Systems Talking Therapies use the IAPTUS electronic record system. This is a nationally recognised bespoke clinical record system used by Talking Therapies services nationwide and is one of only two systems which are nationally recommended for use in this context. The system LORENZO is the electronic record system used by secondary care and Crisis staff in North Staffordshire and Stoke on Trent. Rio is the electronic record system used by secondary care and Crisis staff in South Staffordshire Secondary care providers do not have access to the IAPTUS system. There are important, considered, reasons for this.
1. Talking Therapies in Staffordshire and Stoke on Trent treat a large number of NHS staff for therapy. They have been consented that their notes will remain confidential from other NHS services unless there are issues of risk or safeguarding, to assure them that their colleagues will not be able to view those psychological therapy notes. To open this access to IAPTUS and other NHS Staff poses a risks of breaches of confidentiality and a risk that staff will no longer come forward to access the service.

2. All patients have been consented on the basis that only their direct care team will have access to their notes. As around 30,000- 40,000 patient records are created annually on the system, it would be impossible to re-consent those people historically if access to the system was to change.

3. Staff supervision notes, which are notes which document oversight and input from a supervisor and any guidance provided to ensure the quality of the service provided and to ensure that staff receive the necessary support and feedback to perform their roles effectively, are held on IAPTUS. They are held separately to patient records. There is no way of restricting access to these notes to other users.

4. If access were to be widened (which due to points 1,2 and 3 above is currently not something we are considering) additional user accounts would need to be created.

5. If access were given to NSCHT staff, equivalent access would need to be offered to all partners organisations on the contract making the system unwieldy. Very complex Data Protection Impact Assessments would be required regarding information sharing due to the complexities of the number of partner organisations working on the contract and the information all of them would be able to view.

LEGAL\118240\00072\74212422.v1-6/6/25
6. Nationally, it is not usual practice that secondary care staff have access to the Talking Therapies record system for the clinical and cost reasons outlined above. If urgent or serious risk presents in Talking Therapies services, it is standard and expected practice that these risks should be escalated to secondary care within the system immediately as per Talking Therapies national guidance, due to there being no medical staff in the team to advise on this.

7. There is no block within the IAPTUS system to enable users to access only parts of the notes – if access is grated the entire record, plus supervision notes, will be viewable.

Risk Assessments As a service, Staffordshire and Stoke on Trent Talking Therapies introduced a new process of assessing and documenting risk which came into force on 1 May 2025. This is in response to the new national guidance regarding the removal of risk stratification from risk assessment and notes. The process has been undertaken by all Talking Therapies Services led by MPFT and for Staffordshire and Stoke on Trent, this has been led by the MPFT employed Clinical Director and senior clinicians in the service employed by MPFT and NSCHT, under the supervision of the MPFT Associate Director of Safety, Risk and Compliance and MPFT Director of Psychological Services. All staff working in the service received training on the new processes in April 2025. The training comprised of a live training session which was recorded for staff who were absent to watch at their earliest opportunity. A resource pack was also provided to all staff outlining in writing the new processes and requirements for assessing risk and writing this in notes.

Following implementation, a robust auditing process will be taking place monthly from July 2025 to ensure compliance and address any further staff training needs. Should you have any further questions please do not hesitate to contact Legal.services@mpft.nhs.uk.